Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview and management of lower extremity chronic venous disease

Patrick C Alguire, MD, FACP
Sherry Scovell, MD, FACS
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Chronic venous disease refers to a wide spectrum of morphologic (ie, venous dilation) and/or functional abnormalities (eg, venous reflux) of long duration [1-3]. Vein-related problems may or may not be symptomatic and include a wide range of clinical signs that vary from minimal superficial venous dilation to chronic skin changes with ulceration.


Inadequate muscle pump function, incompetent venous valves (reflux), and venous thrombosis or obstruction are causes of elevated venous pressure (venous hypertension), which initiates a sequence of anatomic, physiologic, and histologic changes leading to vein dilation, skin changes, or skin ulceration. The factors that determine whether a given patient will progress from mild to more severe disease are largely unknown. The pathophysiology of chronic venous disease is discussed in detail elsewhere. (See "Pathophysiology of chronic venous disease" and "Post-thrombotic (postphlebitic) syndrome", section on 'Pathophysiology'.)


Chronic vein abnormalities are present in up to 50 percent of individuals [4-7]. However, estimates of prevalence rates of chronic venous disease vary depending upon the population studied [8].

Epidemiologic studies typically focus on defined subsets based upon the visible manifestations of venous disease. Study populations are generally limited to either those with mild abnormalities (telangiectasias, reticular veins), uncomplicated varicose veins with or without venous reflux, or longstanding venous insufficiency (ie, skin changes, venous ulceration). (See 'Clinical features' below.)

While it is convenient to stratify the study of venous abnormalities in this manner, it is important to remember that these subsets represent varying levels of disease severity in a spectrum of a single pathology; risk factors for development are the same. (See 'Risk factors' below.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 15, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53:2S.
  2. Wittens C, Davies AH, Bækgaard N, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678.
  3. O'Donnell TF Jr, Passman MA. Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF)--Management of venous leg ulcers. Introduction. J Vasc Surg 2014; 60:1S.
  4. Zahariev T, Anastassov V, Girov K, et al. Prevalence of primary chronic venous disease: the Bulgarian experience. Int Angiol 2009; 28:303.
  5. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med 1988; 4:96.
  6. Callam MJ. Epidemiology of varicose veins. Br J Surg 1994; 81:167.
  7. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health 1999; 53:149.
  8. Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol 2003; 158:448.
  9. Labropoulos N, Giannoukas AD, Nicolaides AN, et al. The role of venous reflux and calf muscle pump function in nonthrombotic chronic venous insufficiency. Correlation with severity of signs and symptoms. Arch Surg 1996; 131:403.
  10. Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms, and presence of functional disease. J Vasc Surg 2007; 46:322.
  11. Cesarone MR, Belcaro G, Nicolaides AN, et al. 'Real' epidemiology of varicose veins and chronic venous diseases: the San Valentino Vascular Screening Project. Angiology 2002; 53:119.
  12. Lee AJ, Evans CJ, Allan PL, et al. Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study. J Clin Epidemiol 2003; 56:171.
  13. Carpentier PH, Maricq HR, Biro C, et al. Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France. J Vasc Surg 2004; 40:650.
  14. Coon WW, Willis PW 3rd, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48:839.
  15. Barwell JR, Taylor M, Deacon J, et al. Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers. Eur J Vasc Endovasc Surg 2000; 20:363.
  16. Zamboni P, Cisno C, Marchetti F, et al. Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. Eur J Vasc Endovasc Surg 2003; 25:313.
  17. Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007; 335:83.
  18. FEGAN WG. Continuous compression technique of injecting varicose veins. Lancet 1963; 2:109.
  19. Labas P, Ohradka B, Cambal M, et al. Long term results of compression sclerotherapy. Bratisl Lek Listy 2003; 104:78.
  20. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J (Clin Res Ed) 1985; 290:1855.
  21. Callam M. Prevalence of chronic leg ulceration and severe chronic venous disease in western countries. Phlebology 1992; 1(Suppl):6.
  22. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. Br Med J (Clin Res Ed) 1987; 294:1389.
  23. Baker SR, Stacey MC, Jopp-McKay AG, et al. Epidemiology of chronic venous ulcers. Br J Surg 1991; 78:864.
  24. Cornwall JV, Doré CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986; 73:693.
  25. Langer RD, Ho E, Denenberg JO, et al. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med 2005; 165:1420.
  26. Criqui MH, Denenberg JO, Bergan J, et al. Risk factors for chronic venous disease: the San Diego Population Study. J Vasc Surg 2007; 46:331.
  27. Dua A, Desai SS, Heller JA. The Impact of Race on Advanced Chronic Venous Insufficiency. Ann Vasc Surg 2016; 34:152.
  28. Dua A, Heller JA. Advanced Chronic Venous Insufficiency. Vasc Endovascular Surg 2017; 51:12.
  29. Scott TE, LaMorte WW, Gorin DR, Menzoian JO. Risk factors for chronic venous insufficiency: a dual case-control study. J Vasc Surg 1995; 22:622.
  30. Fowkes FG, Lee AJ, Evans CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol 2001; 30:846.
  31. Sadick NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol 1992; 18:883.
  32. Iannuzzi A, Panico S, Ciardullo AV, et al. Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity. J Vasc Surg 2002; 36:965.
  33. Evans CJ, Fowkes FG, Hajivassiliou CA, et al. Epidemiology of varicose veins. A review. Int Angiol 1994; 13:263.
  34. Browse NL. The etiology of venous ulceration. World J Surg 1986; 10:938.
  35. Browse NL, Burnand KG. The cause of venous ulceration. Lancet 1982; 2:243.
  36. Darvall KA, Sam RC, Adam DJ, et al. Higher prevalence of thrombophilia in patients with varicose veins and venous ulcers than controls. J Vasc Surg 2009; 49:1235.
  37. Allison MA, Cushman M, Callas PW, et al. Adipokines are associated with lower extremity venous disease: the San Diego population study. J Thromb Haemost 2010; 8:1912.
  38. Serra R, Buffone G, de Franciscis A, et al. A genetic study of chronic venous insufficiency. Ann Vasc Surg 2012; 26:636.
  39. Anwar MA, Georgiadis KA, Shalhoub J, et al. A review of familial, genetic, and congenital aspects of primary varicose vein disease. Circ Cardiovasc Genet 2012; 5:460.
  40. Vlajinac HD, Radak DJ, Marinkovic JM, Maksimovic MZ. Risk factors for chronic venous disease. Phlebology 2012; 27:416.
  41. Vlajinac HD, Marinkovic JM, Maksimovic MZ, et al. Body mass index and primary chronic venous disease--a cross-sectional study. Eur J Vasc Endovasc Surg 2013; 45:293.
  42. Davies HO, Popplewell M, Singhal R, et al. Obesity and lower limb venous disease - The epidemic of phlebesity. Phlebology 2017; 32:227.
  43. Stacey MC, Burnand KG, Lea Thomas M, Pattison M. Influence of phlebographic abnormalities on the natural history of venous ulceration. Br J Surg 1991; 78:868.
  44. Hanrahan LM, Araki CT, Rodriguez AA, et al. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg 1991; 13:805.
  45. Kahn SR, Hirsch A, Shrier I. Effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis. Arch Intern Med 2002; 162:1144.
  46. Kahn SR, Ginsberg JS. Relationship between deep venous thrombosis and the postthrombotic syndrome. Arch Intern Med 2004; 164:17.
  47. Mohr DN, Silverstein MD, Heit JA, et al. The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study. Mayo Clin Proc 2000; 75:1249.
  48. Cornu-Thenard A, Boivin P, Baud JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.
  49. Stanhope JM. Varicose veins in a population of lowland New Guinea. Int J Epidemiol 1975; 4:221.
  50. Molho-Pessach V, Agha Z, Libster D, et al. Evidence for clinical and genetic heterogeneity in hereditary benign telangiectasia. J Am Acad Dermatol 2007; 57:814.
  51. Sarin S, Shields DA, Farrah J, et al. Does venous function deteriorate in patients waiting for varicose vein surgery? J R Soc Med 1993; 86:21.
  52. Labropoulos N, Leon L, Kwon S, et al. Study of the venous reflux progression. J Vasc Surg 2005; 41:291.
  53. Kostas TI, Ioannou CV, Drygiannakis I, et al. Chronic venous disease progression and modification of predisposing factors. J Vasc Surg 2010; 51:900.
  54. Karahan O, Yavuz C, Kankilic N, et al. Simple blood tests as predictive markers of disease severity and clinical condition in patients with venous insufficiency. Blood Coagul Fibrinolysis 2016; 27:684.
  55. Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003; 38:793.
  56. Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995; 21:635.
  57. Coleridge-Smith P, Labropoulos N, Partsch H, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006; 31:83.
  58. American Board of Plastic Surgery www.abplsurg.org/ModDefault.aspx (Accessed on March 31, 2009).
  59. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm435082.htm (Accessed on March 19, 2015).
  60. Galland RB, Magee TR, Lewis MH. A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy. Eur J Vasc Endovasc Surg 1998; 16:43.
  61. Tisi PV, Beverley CA. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2002; :CD001732.
  62. van den Bos R, Arends L, Kockaert M, et al. Endovenous therapies of lower extremity varicosities: a meta-analysis. J Vasc Surg 2009; 49:230.
  63. Van Den Bos RR, Neumann M, De Roos KP, Nijsten T. Endovenous laser ablation-induced complications: review of the literature and new cases. Dermatol Surg 2009; 35:1206.
  64. Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev 2014; :CD005624.
  65. Carroll C, Hummel S, Leaviss J, et al. Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins. Br J Surg 2014; 101:1040.
  66. Pan Y, Zhao J, Mei J, et al. Comparison of endovenous laser ablation and high ligation and stripping for varicose vein treatment: a meta-analysis. Phlebology 2014; 29:109.
  67. Darvall KA, Bate GR, Adam DJ, Bradbury AW. Recovery after ultrasound-guided foam sclerotherapy compared with conventional surgery for varicose veins. Br J Surg 2009; 96:1262.
  68. Biemans AA, Kockaert M, Akkersdijk GP, et al. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg 2013; 58:727.
  69. Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose veins. N Engl J Med 2014; 371:1218.
  70. Rasmussen L, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013; 58:421.
  71. Davies HO, Popplewell M, Darvall K, et al. A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins. Phlebology 2016; 31:234.
  72. Carradice D, Mekako AI, Hatfield J, Chetter IC. Randomized clinical trial of concomitant or sequential phlebectomy after endovenous laser therapy for varicose veins. Br J Surg 2009; 96:369.
  73. El-Sheikha J, Nandhra S, Carradice D, et al. Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins. Br J Surg 2014; 101:1093.
  74. Schanzer H. Endovenous ablation plus microphlebectomy/sclerotherapy for the treatment of varicose veins: single or two-stage procedure? Vasc Endovascular Surg 2010; 44:545.
  75. Lane TR, Kelleher D, Shepherd AC, et al. Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial. Ann Surg 2015; 261:654.
  76. Kokkosis AA, Schanzer H. Anatomical and clinical factors favoring the performance of saphenous ablation and microphlebectomy or sclerotherapy as a single-stage procedure. Phlebology 2015; 30:627.
  77. Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev 2015; :CD009648.
  78. Goel RR, Abidia A, Hardy SC. Surgery for deep venous incompetence. Cochrane Database Syst Rev 2015; :CD001097.
  79. Zenilman J, Valle MF, Malas MB, et al. Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities. Report No: 13(14)-EHC121-EF, Agency for Healthcare Research and Quality (US); Rockland, MD 2013.
  80. Stacey MC, Burnand KG, Layer GT, Pattison M. Calf pump function in patients with healed venous ulcers is not improved by surgery to the communicating veins or by elastic stockings. Br J Surg 1988; 75:436.
  81. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.
  82. Puggioni A, Marks N, Hingorani A, et al. The safety of radiofrequency ablation of the great saphenous vein in patients with previous venous thrombosis. J Vasc Surg 2009; 49:1248.
  83. Gloviczki P, Bergan JJ, Menawat SS, et al. Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry. J Vasc Surg 1997; 25:94.
  84. Adam DJ, Bello M, Hartshorne T, London NJ. Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux. Eur J Vasc Endovasc Surg 2003; 25:469.
  85. Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004; 363:1854.
  86. Alden PB, Lips EM, Zimmerman KP, et al. Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence. Ann Vasc Surg 2013; 27:75.
  87. O'Donnell TF Jr. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg 2008; 48:1044.
  88. Thibault PK, Lewis WA. Recurrent varicose veins. Part 2: Injection of incompetent perforating veins using ultrasound guidance. J Dermatol Surg Oncol 1992; 18:895.
  89. Guex JJ. Ultrasound guided sclerotherapy (USGS) for perforating veins (PV). Hawaii Med J 2000; 59:261.
  90. van Gent WB, Catarinella FS, Lam YL, et al. Conservative versus surgical treatment of venous leg ulcers: 10-year follow up of a randomized, multicenter trial. Phlebology 2015; 30:35.
  91. Neto FC, de Araújo GR, Kessler IM, et al. Treatment of severe chronic venous insufficiency with ultrasound-guided foam sclerotherapy: a two-year series in a single center in Brazil. Phlebology 2015; 30:113.
  92. Pfeifer JR. Sclerotherapy. In: Procedures for Primary Care Medicine, Pfenninger JL (Ed), Mosby-Year Book, 1994.
  93. Sales CM, Bilof ML, Petrillo KA, Luka NL. Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann Vasc Surg 1996; 10:186.
  94. Puggioni A, Lurie F, Kistner RL, Eklof B. How often is deep venous reflux eliminated after saphenous vein ablation? J Vasc Surg 2003; 38:517.
  95. Zhu HP, Zhou YL, Zhang X, et al. Combined endovenous laser therapy and pinhole high ligation in the treatment of symptomatic great saphenous varicose veins. Ann Vasc Surg 2014; 28:301.
  96. Mueller RL, Raines JK. ClariVein mechanochemical ablation: background and procedural details. Vasc Endovascular Surg 2013; 47:195.
  97. Milleret R, Huot L, Nicolini P, et al. Great saphenous vein ablation with steam injection: results of a multicentre study. Eur J Vasc Endovasc Surg 2013; 45:391.
  98. Rueda CA, Bittenbinder EN, Buckley CJ, et al. The management of chronic venous insufficiency with ulceration: the role of minimally invasive perforator interruption. Ann Vasc Surg 2013; 27:89.
  99. Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up. J Vasc Surg 1994; 19:391.
  100. Eklof BG, Kistner RL, Masuda EM. Venous bypass and valve reconstruction: long-term efficacy. Vasc Med 1998; 3:157.